Mosaic Life Care
Clinical Documentation Specialist
Pay$54766.40 - $87630.40 / year
LocationSaint Joseph/Missouri
Employment typeFull-Time
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Job Description
- Req#: req18123
- Clinical Documentation Specialist
- Inpatient Coding
- Full Time Status
- Day Shift
- Pay: $54,766.40 - $87,630.40 / year
- This position provides support, consultation, compliance to evidence-based care, and clinical documentation practices. Facilitates and drives improvements in the clinical performance initiatives and helps to maintain regulatory compliant documentation. Performance relies on general nursing/clinical knowledge, including pathophysiology, pharmacology, regulatory requirements and ACDIS professional guidelines. Advanced communication and education to a broad audience including medical staff, patients, clinical departments in the form of specific chart reviews and broad presentation/education. Collaborates regarding clinical and coding knowledge with key stakeholders within the organization. Responsibilities include concurrent review of the clinical documentation to obtain the most accurate and complete physician documentation that appropriately supports the severity of illness, risk of mortality and proper reimbursement.
- This position works under the supervision of the Manager and is employed by Mosaic Health Systems.
- Conducts initial concurrent review and ongoing re-reviews of clinical documentation for all selected admissions to initiate the tracking process and document findings.
- Assigns and updates working DRG for encounters, reviewing in a timely manner and documenting thoroughly in clinical documentation improvement system.
- Identifies need to clarify documentation in records and initiates communication with physician or physician extender utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.
- Utilizes monitoring tools to track the progress of the concurrent review program, interprets tracking information and reports findings.
- Provides information and education as necessary to physicians and ancillary staff. This includes participation on work teams.
- Other duties as assigned
- All required education is a minimum requirement. Higher levels of education are acceptable. Associate's Degree nursing required. Bachelor's Degree nursing preferred.
- RN - Registered Nurse - State Licensure And/Or Compact State Licensure in state, depending upon designated work location is required. AND CCDS Certification - Certificated Clinical Documentation Specialist to be obtained within two years of hire is required. OR CDIP Certification - Certified Documentation Information Practitioner to be obtained within two years of hire required.
- 3 Years- Clinical experience in an ICU/Critical Care acute care setting is required. 1 year experience in clinical documentation integrity functions is preferred.
DetailsSummaryDutiesQualificationsAbout the company
Mosaic Life Care provides health care and life care at a location near you in St. Joseph and the surrounding area. We are a Mayo Clinic Care Network member.